J Korean Neurosurg Soc.  2018 Jul;61(4):525-529. 10.3340/jkns.2018.0002.

Fractionated Stereotactic Radiosurgery for Brain Metastases Using the Novalis Tx® System

• Lim TK
• Kim WK
• Yoo CJ
• Kim EY
• Kim MJ
• Yee GT

• KMID: 2417330
• DOI: http://doi.org/10.3340/jkns.2018.0002

Abstract

OBJECTIVE
To evaluate the efficacy of fractionated stereotactic radiosurgery (FSRS) performed using the Novalis Tx® system (BrainLAB AG, Feldkirchen, Germany; Varian Medical Systems, Palo Alto, CA, USA) for brain metastases.
METHODS
Between March 2013 and July 2016, 23 brain metastases patients were admitted at a single institute. Twenty-nine lesions too large for single session stereotactic radiosurgery or located in the vicinity of eloquent structures were treated by FSRS. Based on the results obtained, we reviewed the efficacy and toxicity of FSRS for the treatment of brain metastases.
RESULTS
The most common lesion origin was lung (55%) followed by breast (21%). Median overall survival was 10.0 months (95% confidence interval [CI], 4.9-15.0), and median progression-free survival was 10.0 months (95% CI, 2.1-13.9). Overall survival rates at 1 and 2 years were 58.6% and 36.0%, respectively. Local recurrence and neurological complications affecting morbidity each occurred in two cases.
CONCLUSION
FSRS using the Novalis-Tx® system would appear to be an effective, safe noninvasive treatment modality for large and eloquently situated brain metastases. Further investigation is required on a larger number of patients.

Keyword

Stereotactic radiosurgery; Brain tumor; Radiosurgery; Metastasis

MeSH Terms

Brain Neoplasms
Brain*
Breast
Disease-Free Survival
Germany
Humans
Lung
Neoplasm Metastasis*
Radiosurgery*
Recurrence
Survival Rate

Figure

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  Fig. 1. Overall and progression free survivals of patients that underwent FSRS for brain metastases. FSRS : fractionated stereotactic radiosurgery.

Reference

References

1. Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 295:2483–2491. 2006.

2. Barnett GH, Linskey ME, Adler JR, Cozzens JW, Friedman WA, Heilbrun MP, et al. Stereotactic radiosurgery--an organized neurosurgerysanctioned definition. J Neurosurg. 106:1–5. 2007.

3. Coffey RJ. Boost gamma knife radiosurgery in the treatment of primary glial tumors. Stereotact Funct Neurosurg 61 Suppl. 1:59–64. 1993.

4. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the radiation therapy oncology group (RTOG) and the European organization for research and treatment of cancer (EORTC). Int J Radiat Oncol Biol Phys. 31:1341–1346. 1995.

5. Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 45:228–247. 2009.

6. Ernst-Stecken A, Ganslandt O, Lambrecht U, Sauer R, Grabenbauer G. Phase II trial of hypofractionated stereotactic radiotherapy for brain metastases: results and toxicity. Radiother Oncol. 81:18–24. 2006.

7. Friedman WA, Foote KD. Linear accelerator radiosurgery in the management of brain tumours. Ann Med. 32:64–80. 2000.

8. Fuss M, Salter BJ, Cheek D, Sadeghi A, Hevezi JM, Herman TS. Repositioning accuracy of a commercially available thermoplastic mask system. Radiother Oncol. 71:339–345. 2004.

9. Jeong WJ, Park JH, Lee EJ, Kim JH, Kim CJ, Cho YH. Efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases. J Korean Neurosurg Soc. 58:217–224. 2015.

10. Jin JY, Ryu S, Faber K, Mikkelsen T, Chen Q, Li S, et al. 2D/3D image fusion for accurate target localization and evaluation of a mask based stereotactic system in fractionated stereotactic radiotherapy of cranial lesions. Med Phys. 33:4557–4566. 2006.

11. Kondziolka D, Lunsford LD, Loeffler JS, Friedman WA. Radiosurgery and radiotherapy: observations and clarifications. J Neurosurg. 101:585–589. 2004.

12. Lawrence YR, Li XA, el Naqa I, Hahn CA, Marks LB, Merchant TE, et al. Radiation dose-volume effects in the brain. Int J Radiat Oncol Biol Phys. 76(3 Suppl):S20–S27. 2010.

13. Leksell L. Cerebral radiosurgery. I. Gammathalanotomy in two cases of intractable pain. Acta Chir Scand. 134:585–595. 1968.

14. Leksell L. Stereotactic radiosurgery. J Neurol Neurosurg Psychiatry. 46:797–803. 1983.

15. Leksell L. The stereotaxic method and radiosurgery of the brain. Acta chir scand. 102:316–319. 1951.

16. Lutz W, Winston KR, Maleki N. A system for stereotactic radiosurgery with a linear accelerator. Int J Radiat Oncol Biol Phys. 14:373–381. 1988.

17. Mayo C, Martel MK, Marks LB, Flickinger J, Nam J, Kirkpatrick J. Radiation dose-volume effects of optic nerves and chiasm. Int J Radiat Oncol Biol Phys. 76(3 Suppl):S28–S35. 2010.

18. Mayo C, Yorke E, Merchant TE. Radiation associated brainstem injury. Int J Radiat Oncol Biol Phys. 76(3 Suppl):S36–S41. 2010.

19. Minniti G, D’Angelillo RM, Scaringi C, Trodella LE, Clarke E, Matteucci P, et al. Fractionated stereotactic radiosurgery for patients with brain metastases. J Neurooncol. 117:295–301. 2014.

20. Minniti G, Scaringi C, Paolini S, Lanzetta G, Romano A, Cicone F, et al. Single-fraction versus multifraction (3 × 9 Gy) stereotactic radiosurgery for large (>2 cm) brain metastases: a comparative analysis of local control and risk of radiation-induced brain necrosis. Int J Radiat Oncol Biol Phys. 95:1142–1148. 2016.

21. Murai T, Ogino H, Manabe Y, Iwabuchi M, Okumura T, Matsushita Y, et al. Fractionated stereotactic radiotherapy using Cyberknife for the treatment of large brain metastases: a dose escalation study. Clin Oncol (R Coll Radiol). 26:151–158. 2014.

22. Ogura K, Mizowaki T, Ogura M, Sakanaka K, Arakawa Y, Miyamoto S, et al. Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk factors. J Neurooncol. 109:425–432. 2012.

23. Sanghavi SN, Miranpuri SS, Chappell R, Buatti JM, Sneed PK, Suh JH, et al. Radiosurgery for patients with brain metastases: a multi-institutional analysis, stratified by the RTOG recursive partitioning analysis method. Int J Radiat Oncol Biol Phys. 51:426–434. 2001.

24. Solberg TD, Medin PM, Mullins J, Li S. Quality assurance of immobilization and target localization systems for frameless stereotactic cranial and extracranial hypofractionated radiotherapy. Int J Radiat Oncol Biol Phys. 71(1 Suppl):S131–S135. 2008.

25. Tryggestad E, Christian M, Ford E, Kut C, Le Y, Sanguineti G, et al. Inter- and intrafraction patient positioning uncertainties for intracranial radiotherapy: a study of four frameless, thermoplastic mask-based immobilization strategies using daily cone-beam CT. Int J Radiat Oncol Biol Phys. 80:281–290. 2011.

26. Wang CC, Floyd SR, Chang CH, Warnke PC, Chio CC, Kasper EM, et al. Cyberknife hypofractionated stereotactic radiosurgery (HSRS) of resection cavity after excision of large cerebral metastasis: efficacy and safety of an 800 cGy × 3 daily fractions regimen. J Neurooncol. 106:601–610. 2012.